Laparoscopic Ventral Hernia Repair

Chan W. Park, MD, FACS

Assistant Professor of Surgery

• Basics

• Bridging

• Defect Closure

• Mesh fixation

• Positioning system

Each hernia is unique…

Approach to the Hernia Patient

• Individualized approach

• Complete History and Physical

• CT Scan – Recurrent hernia

– Atypical location

– Obesity

• Old operative notes whenever possible

• Routine laboratory studies, nutritional panel

Hernia Grading System

Ventral Hernia Working Group. Surgery 148:3

Risk factors for Hernias

• Obesity • Diabetes Mellitus • Smoking

• COPD • Advanced age • Malnutrition

• Immunosuppression, steroids • Radiation Therapy • Connective tissue Disorders

Obesity and Abd Pressure

• 45 morbidly obese (BMI 55)

– 12mm (+ 0.8) Hg in obese

– 0mm (+ 2) Hg in controls

Underweight < 19

Normal 19 - 25

Overweight 26 - 29

Obese Class I 30 - 35

Obese Class II 35 - 39.9

Morbid Obesity > 40

Super Obesity > 50

BMI = Weight kg/Height m2

BMI 40 = approximately 100 lbs above ideal weight

Definition of Obesity

66%

as of

2004!!

Sjostrom, et al. NEJM 2007

Weight Loss is NOT easy

“Staged” hernia repair

Preoperative Goals: Patient Discussion

• Set realistic expectations:

– Goals of repair

– Timing of repair

– Understanding magnitude of procedure

– Complications

– Recovery

Preoperative Goals

• Weight Loss – Set specific goals

– Bariatric surgery first if necessary

• Smoking cessation (ideally ≥ 4 weeks)

• Heal chronic wounds

• Increase physical activity

• Optimize nutritional status

• Optimize cardiopulmonary status

Surgical Planning

• OPEN vs. Laparoscopic

Open

Laparoscopic

OPEN vs. LAP ??

Surgical Planning

• Mesh or NO Mesh?

Luije

ndijk

RW

(2000) N

EJM

343(6

):392

-8

Mesh Placement

Overlay

Inlay

Underlay

Awad ZT (2005) JACS 201(1):132

Surgical Planning

• Key concepts:

– Tension-free repair • MUST reduce abdominal pressure

– Mesh UNDERLAY • MOST effective placement strategy

– Minimally invasive approach • MINIMIZES surgical dissection

• MAXIMIZES visualization and recovery

Ventral Hernia Working Group. Surgery 148:3

General Recommendations

Operative Technique • Access

• Adhesiolysis – Sharp dissection

– Energy source only if unavoidable – accept some bleeding

– Direct visualization

• Assess and measure defect – Techniques for doing this?

• Mesh/prosthetic preparation

• Mesh placement – Overlap

– Tacks, sutures, how many sutures?

Access?

Heniford BT. et al. J AM Coll Surg 2000 190(6):645-50

Heniford BT. et al. J AM Coll Surg 2000 190(6):645-50

Operative Technique: Close Defects?

Overall Mesh only 4.8% Primary repair with mesh 3% Recurrent hernia Mesh only 10.5% Primary repair with mesh 4.8%

Banerjee, et al. Surg Endosc (2012) 26:1264–1268

Principles for Hernia Repair 1 2 3

4